Esophageal Cancer: Treatments

Patients with more advanced tumors are encouraged to undergo multimodality therapy with chemotherapy and radiation therapy followed by surgery. Preoperative therapy increases the likelihood of complete removal of the tumor, and increases cure rate.

Surgery

Two types of surgery are used to treat esophageal cancer—endoscopic mucosal resection (EMR) and minimally invasive esophagectomy.

Endoscopic Mucosal Resection (EMR) and BARRX Balloon Ablation


The BARRX Halo Ablation Catheter delivers a short burst of ablative energy circumferentially to the esophagus (balloon length: 4 cm).

Patients with very early cancers of the esophagus can be treated without extensive surgery by a combination of minimally invasive techniques. In Endoscopic mucosal resection (EMR), the portion of the lining that is diseased is removed using an endoscopic procedure. EMR enables the endoscopist to take a sample of tissue for biopsy at the same time as it is being removed. BARRX ablation is a very specific type of ablation, in which heat energy is delivered in a precise and highly controlled manner. In patients who are operative risks, these techniques can be incorporated to open up esophageal blockages or treat small tumors endoscopically.

Stents may also be used to enable patients with esophageal blockages to swallow. Laparoscopic esophagectomyto remove a diseased lower esophagus is becoming an alternative procedure to the more traditional surgical methods, especially in early-stage esophageal cancers. These and other techniques of esophageal cancer resection pioneered at Columbia result in some of the highest cure rates ever reported.

We perform many of our esophageal resections for cancer using laparoscopy or thoracoscopy. These minimally invasive approaches can significantly reduce the post operative convalescence, and speed recovery. Not all patients are candidates for minimally invasive approaches, but our considerable experience with open surgery enables us to select appropriate patients for minimally invasive procedures.
Minimally Invasive Esophagectomy (MIE)


NewYork-Presbyterian/Columbia surgeons are pioneers in Minimally Invasive Esophagectomy (MIE) and train surgeons around the world in MIE techniques. Our program uses MIE for 80 percent of esophageal procedures. Just as in open surgery for esophageal cancer, MIE involves removal of the esophagus and lymph nodes.
In all esophagectomy procedures, the surgeon makes an incision in the abdomen, separates the esophagus from the stomach, and utilizes a portion of the stomach to fashion a replacement esophagus. The remaining portion of the stomach retains its normal function. Additional incisions are made in the chest and/or neck, depending upon the portion of the esophagus that is diseased, as well as the patient's anatomy:

• Trans-hiatal esophagectomy (THE) involves an incision in the abdomen as well as the neck. THE is generally performed for early-stage cancers, and is routinely done minimally invasively.

• Ivor Lewis esophagectomy (also known as trans-thoracic esophagectomy, or TT) involves an incision in the abdomen as well as the chest. This procedure is employed when the tumor or cancerous tissues are located in the upper part of the esophagus.

• A three-incision option involves access to the abdomen, the chest, and the neck.We perform all of these procedures using minimally invasive approach, although open surgery may be more appropriate depending upon the patient's clinical characteristics and the location of the diseased portion of the esophagus.

Patients should only have an esophagectomy performed by a specially trained thoracic or general surgeon highly skilled in this procedure.

More information can be found here http://www.columbiasurgery.org/esophageal/esophagectomy.html

Chemotherapy

Chemotherapy drugs are given through a vein or by mouth to destroy the cancer.

Chemoradiation.
By itself, chemotherapy rarely cures esophageal cancer. It’s often paired with radiation therapies and referred to as chemoradiation. This approach can be used before surgery, to shrink the cancer and make it easier to remove (neoadjuvant treatment). It may also be used after surgery to kill any remaining tumor cells (adjuvant treatment).
Chemoradiation, or chemotherapy alone, can also be used to help control pain or trouble swallowing when the cancer can't be cured (palliative treatment).
Chemotherapy is given in cycles, with each treatment followed by a rest period. Each cycle typically lasts for a few weeks.

Innovative chemotherapy approaches: A variety of conventional chemotherapy regimens can help to manage both locally advanced and metastatic esophageal cancer, including combination regimens, such as EOX, ECF, XELOX. Folfox, Carboplatinum/Taxol.

Recently, it has also been understood that certain biomarkers can identify patients who can benefit from the addition of targeted therapies, such as the monoclonal antibody, Herceptin for patients with cancers that produce a particular protein called Erbb2 and routine testing is performed at Columbia University Medical Center to assure that the right patients could benefit from such additional treatments. Also, CUMC is at the forefront of personalized medicine and now can offer patients an unprecedented, broad genetic panel to test the cancers for a large variety of genetic aberrations that might further identify effective treatment options.

In addition, some patients might benefit from the addition of so-called antiangiogenic agents (drugs that block the tumors blood supply), such as ramucirumab.

Lastly, CUMC researchers are able to offer access to state-of-the art clinical studies involving unique targeted agents or now also immunotherapies that can possibly help reactivate the immune system to fight the cancer better.

Radiation Therapy

Our radiation oncology colleagues offer sophisticated treatment technology for patients with esophageal cancer, including innovative radiation techniques such as IMRT and SBRT. Radiation therapy may be used with curative intent or to relieve symptoms, such as an inability to swallow solid foods.

With advanced radiation therapy techniques doctors can better target tumors while reducing the radiation to nearby healthy tissues. Here at HICCC our radiation oncology experts have the ability to provide “state of the art” treatments for esophageal disease.

Your radiation oncologist will design the optimal treatment plan for you with you that will provide you the best optimal results. Treatment delivery can be daily, weekly, every other day, and or single fraction.

If radiation treatment is recommended, a radiation oncologist will work with our radiation oncology team to create a course of treatment. At Columbia University Irving Medical Center treatment modalities available and most commonly used for this cancer are External Beam Radiation Therapy, 3D Conformal Radiotherapy, Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy (IMRT)Stereotactic Body Radiotherapy (SBRT) and Brachytherapy.